Proximal Portion Research Articles

Three-dimensional characterization of the Búzios Field reveals implications on the tectonostratigraphic evolution of the Santos Basin using combined seismic attributes and well-logs analysis

The Búzios Field is one of the most prolific petroleum fields along the Eastern Brazilian Margin. Despite significant research conducted restrictedly on the pre-salt reservoirs, few studies have focused on the three-dimensional characterization of the entire Búzios Field area. Therefore this work aims to spatially characterize a volume along the Búzios Field area using 3D seismic volume interpretation, seismic attributes, and well-log data. The combined use of these tools allowed the understanding of several parameters concerning the tectonostratigraphic evolution of the Santos Basin. Within the mapped area, we identified five units: Syn-Rift I, Syn-Rift II, Post-Rift I, Post-Rift II, Drift I, and Drift II. The 3D model reveals significant features such as the depth variation of the Syn-Rift I unit and the heterogeneous morphology of the Post-Rift II unit. The Syn-Rift I unit is deeper towards the N-NW and shallower towards the S-SE due to a regional half-grabens system. This system impacts the pre-salt geometry and thickness, as structural highs and lows are relevant factors in sediment accommodation. The Post-Rift I unit has a predominantly regular geometry and thickness but tends to thicken towards the S-SE and exhibits slight downward flexure towards the NE in the southeast of the Búzios Field. In three dimensions, the heterogeneous morphology of the Post-Rift II unit is evidenced by the variable thickness and irregular topography, accounting for the intense halokinesis in the Santos Basin. Above the evaporite layer, the thickness of the Drift I unit is highly conditioned by salt morphology, with thicker and deformed packages in areas of thinner salt section. On the other hand, the Drift II unit shows relatively constant thickness with minor variations near fault zones. Comparisons with other fields within the Santos Basin (Tupi and Sapinhoá/Lapa) reveal differences in layer thickness, mobilization, and rotation of the syn-rift blocks. The Post-Rift I layer (Barra Velha Fm.) and the Post-Rift II package (Ariri Fm.) are thinner and less mobilized in the Búzios Field area. Moreover, the syn-rift blocks are less rotated, and the internal reflectors have a lower inclination in the study area when compared to these other fields. Therefore, this research concludes that the lower mobilization of salt, the lower thickness of the post-rift package, and the minor syn-rift block rotation observed in the Búzios Field area are associated with the relative distance from the continental margin and, consequently, with the amount of displacement generated by the South Atlantic Rift. In this case, the Búzios Field is located in a more proximal portion than the Tupi and Sapinhoá/Lapa fields, exhibiting features suggestive of a lower displacement.

Hemodynamic Characteristics of Intracranial Atherosclerotic Stenosis: A Pilot Study of Contrast Enhancement Time-Density Curves Based on Regions of Interest.

The present study aimed to analyze the hemodynamic characteristics of occluded vessels responsible for acute ischemic stroke and to diagnose the occlusion types. Multimodal computed tomography (CT) was used to accurately identify the range of occlusion of large intracranial vessels. Regions of interest (ROI 1-3 ) were manually delineated at sites 2 mm away from the proximal, middle, and distal portions of each occlusion, generating 3 contrast enhancement time-density curves. The peak CT attenuation values, or Hounsfield units (H 1-3 ), and time-to-peak values (T 1-3 ) were extracted from each curve. H 0 and T 0 of the time-density curve, based on ROI 0 of the automatically recognized input artery, were used as the baseline values with which the odds ratios of each parameter, H 1-3/0 and T 1-3/0 , were obtained. The present study aimed to establish prediction models for intracranial atherosclerotic stenosis (ICAS) based on each ROI's time-density curve. Among the 33 acutely occluded intracranial vessels, 10 were found to have ICAS, whereas 23 did not, based on the diagnostic criteria. Significant differences were observed in patient sex, neutrophil-to-lymphocyte ratio upon admission, Alberta Stroke Program Early CT Score 24-48 hours after reperfusion therapy, and H 1/0 , H 3/0 , and T 3/0 between the ICAS and non-ICAS groups ( P < 0.05). The prediction model (model 3) based on the ROI 3 time-density curve showed the best performance for the diagnosis of ICAS (area under the curve, 0.944; 95% confidence interval, 0.854-1.000). The prediction models based on ROI 1 (model 1) and ROI 2 (model 2) showed moderate diagnostic performance (area under the curve, 0.817 vs 0.822, respectively). The best visualization for proximal occlusions was in the first phase (arterial phase) of multiphase CT angiography, and in the second phase (early venous phase) for distal occlusions. The contrast enhancement time-density curves of the ROIs at all evaluated portions of the acute ischemic stroke occlusions provided a visual display of the blood flow characteristics of the responsible vessels. The time-density curve of the ROI placed 2 mm from the distal occlusion was a combined effect of residual blood flow and collateral establishment, thus providing good performance for the diagnosis of ICAS.

Case Report: Acute Intrathoracic Sleeve Migration with Partial Volvulus after Laparoscopic Sleeve Gastrectomy and Hiatal Hernia Repair

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States and is widely accepted due to its technical ease and effectiveness. Concomitant hiatal hernia repair, if detected during an LSG, is recommended. Intrathoracic sleeve migration (ITSM), a sliding hiatal hernia that develops after LSG, is a rare complication of this procedure. This report presents an early case of ITSM due to intermittent retching, resulting in postoperative incarceration of the proximal sleeve. The patient is a 28-year-old female who underwent concomitant LSG and hiatal hernia repair and was readmitted for acute entrapment of the proximal portion of the sleeve. The patient underwent re-operation with reduction of the proximal sleeve, and omentopexy was performed for stabilization. Intraoperative esophagogastroduodenoscopy was performed to ensure the detorsion and patency of the sleeve before the surgery. No additional hiatal hernia repair was attempted. ITSM with incarceration is an interesting phenomenon that is underrecognized and underreported. It can present postoperatively with reflux symptoms and poor oral tolerance. Failure to make an accurate diagnosis and intervene can result in prolonged hospitalization and poor patient outcomes.

Management of the left subclavian artery during aortic arch replacement using a frozen elephant trunk approach: a review.

The frozen elephant trunk (FET) technique for total aortic arch replacement extends repair into the proximal portion of the descending thoracic aorta. Several techniques and modifications of total arch replacement have been described in the literature, and many of these iterations are related to facilitating the distal anastomosis while preserving flow to the left subclavian artery (LSCA), as well as maintaining posterior circulation of the brain via the vertebral artery, by reducing the circulatory arrest time during reconstruction. Because of the LSCA's posterior and deep anatomic location in the chest, particularly in obese patients, this revascularization is often challenging; additional concerns regarding LSCA revascularization include patients with large aortic arch aneurysms, those with dissected or calcified arteries, and reoperation. A careful plan for reconstruction is necessary. Whether revascularization is performed preoperative, intraoperative, or postoperatively, every effort should be made to include the left subclavian artery as part of the operational approach. Revascularization techniques include reimplantation as part of the island patch or direct anastomosis, stenting, bypass, transposition or a hybrid approach. The importance of maintaining circulation of the LSCA cannot be overstated. Preserving flow to the spinal cord via collaterals minimizes the risk of cord injury during FET procedure. In patients with a patent left internal mammary artery bypass, left arm arteriovenous fistula for hemodialysis, dominant circulation, or direct aortic origin of the left vertebral artery, revascularization is necessary as well. In the case of initial sacrifice, arm claudication or steal syndrome usually dictates delayed extra-anatomic revascularization in the postoperative period.

Pre-surgical three-dimensional transesophageal echocardiography commissural view of the right and non-coronary commissure of the patient described in Figure 6. The retracted and thickened right coronary l aflet is visualized, which is restricted in its motion both related to fusion with the left coronary leaflet, but also extension of fibrotic tissue from the ventricular septal defect patch over the proximal portion

Pre-surgical three-dimensional transesophageal echocardiography commissural view of the right and non-coronary commissure of the patient described in Figure 6. The retracted and thickened right coronary l aflet is visualized, which is restricted in its motion both related to fusion with the left coronary leaflet, but also extension of fibrotic tissue from the ventricular septal defect patch over the proximal portion

Duo-decapolar catheter entrapment in the Chiari network: successful extraction with the snare catheter

BackgroundThe Chiari network (CN) is the net-like embryonic remnants of the right valve of the sinus venosus. Catheter entrapment by CN is a not uncommon complication during catheter manipulation inside the right atrium (RA).Case presentationA 49-year-old man with atrial fibrillation was admitted for cryoablation. Transesophageal echocardiography revealed a prominent CN in the RA. Through the sheath placed in the right femoral vein, a diagnostic electrophysiologic duo-decapolar (DD) catheter (Livewire, St Jude Medical, St Paul, MN) was advanced. The catheter tip was knotted after multiple rotations in the RA to properly locate the DD catheter at the RA wall and coronary sinus (CS). Initial attempts to disentangle the folded catheter tip by traction and rotation maneuvers were unsuccessful. We inserted the large-bore sheath (Sentrant; Medtronic, 20 Fr) into the patient’s left femoral vein and then, captured the folded catheter tip with the 20-mm circular snare catheter (Snare Kit, Medtronic, Minneapolis, MN). Then, we cut the proximal portion of the DD catheter externally and removed it retrogradely through the Flexcath sheath. We found that the catheter tip was entrapped by the fibrous tissue of the CN. After a successful retrieval, cryoablation was conducted as planned. Follow-up echocardiography did not reveal any peri-procedural complications.ConclusionsThe electrophysiological procedure that exists at the RA entails a potential risk of catheter entrapment manipulating the catheter at the RA. If catheter entrapment occurs during the procedure, the entrapped catheter may be removed via a large-bore sheath using a snare catheter.

Magnetic resonance imaging findings of the lower limb muscles in anti-mitochondrial M2 antibody-positive myositis

Anti-mitochondrial M2 antibody (AMA-M2)-positive myositis is an idiopathic inflammatory myopathy (IIM). Of all patients with myositis, 2.5–19.5% have AMA-M2 antibodies. However, the detailed distribution of muscles affected in AMA-positive myositis is unknown. Therefore, we examined lower muscle magnetic resonance imaging (MRI) findings of patients with AMA-positive myositis. Among the 63 patients with IIM at our institute, 5 (7.9%) were positive for AMA-M2 antibodies. However, one was also positive for anti-Jo1 antibodies; therefore, four patients were finally participated in this study. All patients had high-intensity MRI signals in the proximal muscles, including the gluteus maximus and iliopsoas muscles, and in the thigh muscles, including the vastus lateralis, vastus medialis, adductor magnus, and semimembranosus muscles. Lower leg muscles were relatively spared. Fascial edema was observed in all patients and was also present in the lower leg muscles. Subcutaneous edema was observed, particularly in the proximal portion of the lower limbs. In AMA-positive myositis, proximal muscles, including the gluteus maximus, vastus lateralis, adductor magnus, and the semimembranosus, were markedly affected, while the lower leg muscles were relatively preserved. Additionally, fascial edema was evident even in lower leg muscles. Therefore, muscle MRI can be a useful diagnostic aid for AMA-positive myositis.

Preliminary feasibility study of a new partially covered self-expandable metal stent with an anchoring flange for EUS-guided hepaticogastrostomy (with videos)

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has a risk of serious procedural adverse events (AEs), but few dedicated devices for EUS-HGS are available. We evaluated the feasibility of a new partially covered self-expandable metal stent (PCSEMS) with an anchoring flange for EUS-HGS. The feasibility of a stent featuring a proximal radiopaque uncovered portion 1.5 cm in length and a distal anchoring flange 20 mm in diameter was evaluated in consecutive patients undergoing EUS-HGS for unresectable malignant biliary obstruction. The primary outcome was technical and clinical success with regard to the EUS-HGS, and the secondary outcomes were adverse events (AEs), recurrent biliary obstruction (RBO), re-intervention for RBO, and the technical feasibility of peroral cholangioscopy (POC) through the stent in situ. EUS-HGS was performed in 24 patients with unresectable malignant biliary obstruction. The technical and clinical success rates of EUS-HGS were 100% (24/24) and 91.7% (22/24), respectively. AEs developed after EUS-HGS in 8.3% of the patients (2/24, cholangitis). RBO developed in 29.2% of the patients (7/24), with a median cumulative time to RBO of 6.7 months. The causes of RBO were sludge formation (n = 4), hyperplasia at an uncovered portion (n = 2), and nonocclusive cholangitis (n = 1). Re-intervention for RBO had a 100% success rate (7/7), and POC through the stent in situ was technically feasible in seven out of eight patients with a stent diameter of 10 mm. EUS-HGS with a new PCSEMS can alleviate malignant biliary obstruction after failed ERCP. The novel stent evaluated in this study may prevent stent-related AEs including stent migration and allow advanced endoscopic interventions through the HGS route.

Phenotypic features of respiratory function disorders in occupational asthma

The article is devoted to the study of spirographic indicators FEV1, FEV1/FVC, PEF, MEF75, MEF50, and MEF25 as the most informative indicators reflecting the state of bronchial patency at the level of the proximal and distal portions of the bronchial tree in various phenotypes of occupational asthma. The signs of respiratory distress are most pronounced in patients with the occupational COPD phenotype of occupational asthma. Significantly more favorable spirographic picture in terms of FVC, FEV1, PEF, and MEF25VC is observed in the allergic phenotype of occupational asthma. Dynamic determination of forced expiratory flow in various phenotypes of occupational bronchial asthma allows to improve the diagnosis of obstructive disorders in this pathology, optimize the choice of therapeutic and preventive tactics, and predict the course of this pathology.

Association Between Tunnel Position, Tunnel Angle, Graft Signal Intensity, and Graft Thickness in the Reconstructed Posterior Cruciate Ligament

Background: An appropriate tunnel position, tunnel angle, and tunnel-graft angle are important factors for maintaining the stability and mechanical properties of a posterior cruciate ligament (PCL) graft. Purpose: To evaluate the association between tunnel position, tunnel angle, graft signal intensity ratio (SIR), and graft thickness after remnant-preserving PCL reconstruction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were patients who had undergone remnant-preserving single-bundle PCL reconstruction using a tibialis anterior allograft between March 2014 and September 2020 and who had minimum 12-month postoperative magnetic resonance imaging scans. Tunnel position and angle were evaluated via 3-dimensional computed tomography, and their association with graft SIR on both the femoral and the tibial sides was determined. Graft thickness and SIR at 3 areas of the graft were evaluated and compared, and their association with tunnel-graft angle was also determined. Results: Overall, 50 knees (50 patients; 43 male, 7 female) were included. The mean time to postoperative magnetic resonance imaging was 25.8 ± 15.8 months. The mean SIR of the graft’s midportion was higher compared with that of the proximal and distal portions ( P = .028 and P &lt; .001, respectively), and the SIR of the proximal portion was higher compared with that of the distal portion ( P = .002). The femoral tunnel-graft angle was more acute than the tibial tunnel-graft angle ( P = .004). A more anteriorly and distally located femoral tunnel led to a less acute femoral tunnel-graft angle ( P = .005) and a decreased SIR of the proximal portion ( P = .040), and a more laterally located tibial tunnel was associated with a less acute tibial tunnel-graft angle ( P = .024) and a reduced SIR of the distal portion ( P = .044). The mean thicknesses of the graft’s midportion and distal portion were larger than that of the proximal portion ( P &lt; .001). The SIR of the graft’s midportion was positively correlated with its thickness ( r = 0.321; P = .023). Conclusion: The SIR of the proximal portion of the graft around the femoral tunnel was higher than that of the distal portion around the tibial tunnel. An anteriorly and distally positioned femoral tunnel and a laterally positioned tibial tunnel resulted in less acute tunnel-graft angles that were associated with decreased signal intensity.

Pre-anthesis spike growth dynamics and its association to yield components among elite bread wheat cultivars (Triticum aestivum L. spp.) under Mediterranean climate

Wheat (Triticum spp.) grain yield (GY) is highly associated with grain number per unit area (GN m-2). Biomass accumulation and partitioning are essential to understand pre-anthesis spike growth dynamics which determines spike dry matter at anthesis (SDMa) - a GN determinant. Spike growth takes place during the stem elongation period (SE), from terminal spikelet to anthesis, following leaf and spikelet initiation (LS) from sowing to terminal spikelet. In this study, bread wheat cultivars were examined under Mediterranean semi-arid conditions to determine (i) the varietal differences in pre-anthesis phase duration, (ii) whether this variability influences biomass partitioning and spike-related traits, and (iii) to what extent, the genotypic variations in pre-anthesis phase duration and spike growth are associated with yield components. A panel of Israeli commercial bread wheat cultivars were grown in the field during 2016–17 (three environments) and 2017–18 (two environments) and characterized for pre-anthesis phases, floral conditions and spike fertility via histological measurements; spike traits, dry matter accumulation, partitioning at anthesis and maturity and for yield components. Significant variability in the timing of pre-anthesis phases was detected within the tested panel for both LS and SE phases. LS duration was positively associated with growing degree days (GDD) to anthesis across environments (0.72–0.90) while variation in SE was related with differences in GDD to anthesis but to a lesser extent and not in all environments (0.47–0.79). In addition, LS duration, and occasionally SE, were favourably related with a higher dry matter of fertile florets spike-1 (at anthesis) and SDM (at both anthesis and maturity). Principal component analysis (PCA) clearly separates environments and to a lesser extent cultivars within each environment. Two cultivar pairs 'Zahir-Yuval' and 'Negev-Gedera', which flowered concurrently, showed significant differences in the durations of LS and SE phases across most of the environments. Longer LS, in cultivars Zahir and Negev, exhibited increased spikelets spike-1, whereas longer SE (e.g., in Yuval and Gedera) enhanced spike fertility through improving the survival rate of floret primordia (FSR%) of central spikelets. However, there was a trade-off for FSR at the proximal and distal spike portions, resulting in lower grain set (%) leading to reduction of final GN (or GY) in cultivars with longer SE. In the tested panel and under our environmental conditions characterized by growing cycle and Mediterranean climate, the duration of both LS and SE contribute to spike fertility, but LS duration seemed a stronger driver than SE for GN and yield enhancement. Our results highlight the importance of pre-anthesis phases, especially the role of LS in wheat yield increment during the short growing cycle. The varietal combination with variable LS and SE duration could be implemented in breeding pipelines and used as pre-breeding materials for GN improvement. Furthermore, the findings will encourage pre-anthesis traits adoption in Mediterranean bread wheat future breeding programs.

Detection of the Vesical Arteries Using Three-dimensional Digital Subtraction Angiography Relevant to Intra-arterial Infusion Chemotherapy for Bladder Cancer Using Double-balloon Catheters.

This study aims to assess and measure the origin of the superior vesical artery and its distance from the anterior trunk of the internal iliac artery, to which the anticancer drug is infused via double-balloon-occluded arterial infusion bladder-preserving therapy for locally invasive bladder cancer. The 160 pelvic sides of 80 patients were analyzed. Double-balloon catheters were bilaterally introduced into the contralateral superior gluteal artery via the internal iliac arteries using a bilateral transfemoral approach. The proximal balloon is placed at the internal iliac artery, proximally from superior gluteal artery bifurcation, whereas the distal balloon at the origin of the superior gluteal artery to isolate the anterior trunk of the internal iliac artery discharging to the targeted vesical arteries between the balloons. The side hole between the distal and proximal balloons was adjusted at the origin of the anterior trunk of the internal iliac artery to allow clear visualization of the angiographic flow into the bladder. After the distal and proximal balloons were inflated, three-dimensional rotational digital subtraction angiography was performed by simultaneous contrast injection from one extension tube connected to bilateral catheters. The distance (X) between the origins of anterior trunk of the internal iliac artery and superior vesical artery was measured on three-dimensional digital subtraction angiography images, and the origin of the inferior vesical artery was investigated. All superior vesical artery originated from anterior trunk of the internal iliac artery. The mean x was 7.2 mm (range 1.0-22.0 mm). All inferior vesical arterys branched from anterior trunk of the internal iliac artery or its branches. Superior vesical artery commonly originates from the proximal portion of anterior trunk of the internal iliac artery close to superior gluteal artery bifurcation.

Factors influencing the Shear Wave Elastography evaluation of the patellar tendon.

There is no clear standardization for tendon Shear Wave Elastography (SWE), and data regarding the factors that influence the correctness of evaluation are scarce. We aimed to determine the intra- and interobserver agreement in patellar tendon SWE, and to establish the influence of various factors on elasticity values. We recruited 37 healthy volunteers; SWE of the patellar tendon was performed by two examiners. The following factors were analyzed: probe frequency, degree of joint flexion, size of region of interest (ROI), distance of the color box from the probe footprint, utilization of coupling gel as standoff, and the effect of physical exercise on elastic modulus values. Highest overall interobserver [k=0.767, 95%CI (0.717-0.799), p<0.001] and intraobserver agreement [k=0.920 (0.909-0.929) for examiner 1, k=0.891 (0.875-0.905) for examiner 2] was obtained with the knee in the neutral position, using the L18-5 probe. With the knee flexed at 30º and 45º, the elasticity values were higher compared to the neutral position (p<0.001). With the probe immersed in 0.25 and 0.50 cm coupling gel, the median values were lower compared to the probe placed on the skin (p=0.001, p=0.018). The ROI dimensions and the placement of the SWE box at the level of the skin or at 0.5 cm below skin did not significantly influence the elastic modulus. After physical exercise, the elasticity values decreased in the proximal and middle portion of the tendon (p=0.002, p<0.001). The best results obtained in patellar tendon SWE were with the knee in neutral position, in the proximal or middle tendon, after 10 minutes of relaxation and with the probe placed directly on the skin with minimal pressure. The size and position of ROI do not significantly influence the examination.

A new click beetle (Coleoptera: Elateridae) from the mid-Cretaceous Burmese amber underlines the need for an improved tribal classification of Elaterinae

The fossil record of click beetles (Coleoptera: Elateridae) in Cretaceous has been only poorly documented so far. In this study, we describe Burmophysorhinus dusaneki gen. et sp. nov. based on a single, relatively well-preserved, specimen from the mid-Cretaceous Burmese amber. This species represents the fourth species of the subfamily Elaterinae known from the Burmese amber. It is morphologically similar to the recently described Dariuszelater tarnawskii Zhao et al. 2022, with which it shares the complete frontal carina, strongly developed proximal portion of metacoxal plates, tibiae with strongly developed spurs, and long first tarsomeres. Based on this combination of characters, we tentatively place both taxa in the tribe Physorhinini. One of the principal characters usually used for the definition of Physorhinini is the presence of ventral lobe on each tarsomere III. Since this is not present in both fossil taxa, only further discoveries of Mesozoic Physorhinini may help to elucidate if they originally have had simple tarsi and only later during their evolution acquired ventrally lobate tarsomere III, or if they have both simple and lobate tarsomeres III already during their early diversification. The current concept of Physorhinini, as well as of all other tribes in Elaterinae, should be re-evaluated using more lines of evidence. Additionally, we added the identification key to the Elaterinae from Burmese amber.

#6056 NEPHROLOGIC INVOLVEMENT IN A SURGICAL COMPLICATION: WHEN TO SUSPECT A PYELO-DUODENAL FISTULA

Abstract Background and Aims Spontaneous pyeloduodenal fistula is a rare condition occurring primarily after urologic events, in most cases infected kidney stones, pyonephrosis, xanthogranulomatous pyelonephritis, renal tumors, and infected renal cysts, with nowadays 80 cases described. The close relationship between the kidney and the duodenum is a facilitating condition. Method We describe the case of a 78 yo woman admitted in April 2022 for Acute Kidney Injury associated with fever, vomiting, oliguria and metabolic alkalosis. Over the last two years the patient reported recurrent febrile episodes associated with abdominal tenderness and weight loss. Urine cultures showed recurrent bacterial growth and she received antibiotics for recurrent episodes of pyelonephritis and lower urinary tract infections (K. Pneumonie ESBL +, E. Faecalis, P. Mirabilis). She was under nephrologic follow-up with a renal function demonstrating eGFR CKD-EPI of 35-30 ml/min/1.73 m2. In past medical history she reported atrial fibrillation in DOAC, heart failure with preserved ejection fraction, hypertension, previous left occipito-parietal ischemic stroke and right parotid adenoma. On physical examination of the abdomen there was no tenderness, mild pain in the right hypochondrium, Giordano's maneuver mild positive on the right side. Because of the evidence of lithiasis in the right kidney on ultrasound with grade III hydroureteronephrosis, we performed a CT scan with contrast, finding imaging compatible with right pyelonephritis with associated grade IV hydronephrosis, in particular lithiasic formation localized at the level of the right pyelo-ureteral junction (2 × 1cm), with partial involvement of the proximal portion of the ureter, severe calico-pyelic dilatation with overall reduction of the cortico-medullary thickness; diffuse inhomogeneity of the middle and lower thirds of the renal parenchyma, with evidence of some bubbles in contextual areas and inhomogeneity of the perirenal adipose tissue. Reduced nephrographic effect in the post-contrastographic phases and lack of elimination of the contrast in the urographic phase (12 min) were reported. She was started on antibiotics piperacillin-tazobactam and underwent right percutaneous nephrostomy placement. During the procedure we evidenced a communication between the calyx of the right upper calyceal group and an intestinal loop, probably the duodenum (Fig. 1). Results The patient underwent elective laparotomic surgery for right nephrectomy (Fig. 2) and closure of the intestinal fistula with duodenoraffia and omental patch. She was admitted to a post-operative intensive care unit, given comorbidities and the complexity of the operation. She was discharged in 9 days without post-operative complications, with stable renal function. One month after discharge the patient died of pneumonia. Conclusion Pyeloduodenal fistula is an infrequent condition causing occasional or continuous passing of materials between the alimentary canal and urinary tract. The presence of gastrointestinal symptoms and urinary tract alterations may be misinterpreted when occurring. Management of this case required collaboration between several specialists, with particular skills on AKI and CKD, infective complications, interventional radiology and surgical procedures. The outcome was strongly affected by the patient's general condition and comorbidities, with a good short-term outcome but complications on the long-term follow-up. The occurrence of air in the urinary tract is strongly suggestive of communications across the renal pelvis and the gastrointestinal tract. In particular if occurring in the setting of recurrent infections and nephrolithiasis, the diagnosis of pyelo-intestinal fistula should be considered.

Endovascular treatment of a giant splenic aneurysm: a case report

The aim of the present study is to report the endovascular treatment of a giant splenic aneurysm. Female patient, 56 years old, during an outpatient investigation of complaints of sporadic nausea, without associated abdominal pain, a contrast-enhanced tomography was performed, showing two saccular splenic artery aneurysms, one in the proximal third with a diameter of 6.2x4.5cm and one in the middle-distal third of 5.1x4.4cm. Procedure performed in three stages: initially with arteriography of the celiac trunk for therapeutic planning; in a second moment, embolization was performed with splenic artery coils, in a portion distal to the aneurysms, with success; and in a third moment, embolization of the proximal portion of the splenic artery was performed, with a 12mm vascular plug, without intercurrences. Patient with good evolution, discharged in the first postoperative period and in outpatient follow-up. Endovascular treatment is the first choice for correction of LAAs, and advances in methods and materials available allow it to be used as an option in cases of complex anatomy.

P.129 Endovascular coiling of ruptured basilar fenestration aneurysm: case report and review of literature

Background: Basilar fenestration is a rare congenital anomaly. When present, it is commonly found at the proximal portion of the artery near the vertebrobasilar junction. Methods: This is a case report of a ruptured basilar fenestration aneurysm in a 47-year-male successfully treated with endovascular coiling. Results: A 47-year-old male presented with sudden onset headache, neck pain, blurry vision, nausea, vomiting, and diaphoresis. Cerebral angiogram revealed a saccular basilar fenestration aneurysm located at the vertebrobasilar junction measuring 3.1 x 2.6 x 3.4 mm with a 2.3 mm neck. Multiple coils were placed including Target 360 Nano 2mm x 4 cm (Stryker, Kalamazoo, MI, US), Target 360 Nano 1.5 mm x 2 cm (Stryker, Kalamazoo, MI, US), and Target Helical Nano 1.5 mm x 1 cm (Stryker, Kalamazoo, MI, US). A repeat angiogram revealed complete exclusion of the aneurysm with preservation of both vertebral arteries. Conclusions: A literature review was conducted on basilar fenestration aneurysms which included 158 patients from 39 studies. Overall, complete exclusion of the aneurysm was achieved in 75.8% of cases, with 22.4% of cases having residual flow and 1.8% of cases with unreported exclusion status.

Hipparion tracks and horses' toes: the evolution of the equid single hoof.

The traditional story of the evolution of the horse (family Equidae) has been in large part about the evolution of their feet. How did modern horses come to have a single toe (digit III), with the hoof bearing a characteristic V-shaped keratinous frog on the sole, and what happened to the other digits? While it has long been known that the proximal portions of digits II and IV are retained as the splint bones, a recent hypothesis suggested that the distal portion of these digits have also been retained as part of the frog, drawing upon the famous Laetoli footprints of the tridactyl (three-toed) equid Hipparion as part of the evidence. We show here that, while there is good anatomical and embryological evidence for the proximal portions of all the accessory digits (i.e. I and V, as well as II and IV) being retained in the feet of modern horses, evidence is lacking for the retention of any distal portions of these digits. There is also good ichnological evidence that many tridactyl equids possessed a frog, and that the frog has been part of the equid foot for much of equid evolutionary history.

Clear cell chondrosarcoma: A national analysis exploring the demographic features.

e23503 Background: Clear cell chondrosarcoma (CCCS) is an uncommon cancer and variant of chondrosarcoma affecting the proximal portion of long bones, commonly the femur or humerus. This low-grade and slowly progressing malignant tumor is often mistaken for benign tumors (i.e. chondroblastoma), but its histological features of benign giant cells and cells with clear cytoplasm alongside pathologic, roentgenographic, and clinical characteristics aid in its distinction. Accurate identification will guide the establishment of standard treatment algorithms and further improve treatment outcomes. CCCS has an overall 10-year survival rate of 89% with a median time to death from disease of 15.3 years. The National Cancer Database (NCDB) was analyzed to determine how patient demographic characteristics affect the diagnosis of CCCS. Methods: A retrospective cohort study from 2004 to 2020 was conducted using the NCDB. 188 patients were found with a histologically confirmed diagnosis of CCCS (ICD-9242-3). Gender, race, Hispanic origin, insurance coverage, type of treatment facility, and distance from patient residence to treatment facility were analyzed via descriptive statistics and trends in incidence were interpreted using regression analysis. Results: The frequency of patients diagnosed with CCCS has remained consistent since 2004 (R2 = 0.1) with over 11 diagnoses per year. Of the 188 patients found, the average age of diagnosis was 47.8 years (SD = 16.7, range = 14 – 90 years). Approximately two-thirds of patients were male (68.1%) and the remainder were female (31.9%). Most of the patients were White (84.6%). Patient Hispanic status could not be accurately determined due to limited data. More patients were in the top income quartile (31.9%) than those in the second (26.1%), third (19.7%), or fourth (12.2%) quartiles. The other 10.1% were of unknown income status. Most patients were privately insured (61.7%), followed by coverage under Medicare/Medicaid (27.1%). More patients lived in metropolitan counties with a population of 250,000 or more (85%) compared to less-populated urban or rural areas (15%). A large percentage of patients were treated at an academic/research program (61.6%) compared to non-academic programs (38.4%). Patients traveled an average of 65.8 miles (SD = 101.4, range = 0.8 – 793.0) to get to the treatment facility. Conclusions: CCCS remains a rare diagnosis. This study explores a significant gap in existing knowledge on patient characteristics that might present with CCCS. Most patients were White, insured by private insurance, in the top quartile of income earners, and lived in metropolitan areas. This novel study of socioeconomic factors in CCCS patients suggests that patients with higher socioeconomic status in highly-populated areas might have better access to this uncommon diagnosis. As such, additional research to comprehend the role that socioeconomic status might have on CCCS would be beneficial.

Regional muscle features and their association with knee extensors force production at a single joint angle

This study aimed (i) to investigate the role of regional characteristics of the knee extensors muscles (vastus lateralis: VL, vastus intermedius: VI and rectus femoris: RF) in determining maximum-voluntary force (MVF); and (ii) to understand which regional parameter of muscle structure would best predict MVF. Muscle architecture (e.g., pennation angle and fascicle length), muscle volume (Vol), anatomical (ACSA) and physiological cross-sectional-area (PCSA) were measured in the proximal (0–33% of the muscle length), middle (33–66% of the muscle length) and distal (66–100% of the muscle length) portions of each muscle in fifteen healthy males using ultrasound and Magnetic Resonance Imaging (MRI). Knee extensors force was calculated in isometric condition at a single knee joint angle of 90 degrees. Regional ACSA, Vol and PCSA were correlated with MVF production. Regional muscle geometry showed no significant correlations with MVF. Among regions, the middle portion of each muscle was largely correlated with MVF compared to all the other regions (distal and proximal). To understand which regional structural parameter best predicted MVF, a stepwise multiple linear regression was performed. This model showed a significant explanatory power (P < 0.001, R2 = 0.76, adjusted R2 = 0.71), including muscle Vol collected in the mid portions of VL and RF. Even if no significant differences were reported between Vol, PCSA and ACSA in determining MVF, our results showed that the RF and VL volume collected in the middle portion of the muscle length are strong determinants of MVF produced by the knee extensors at 90 degrees joint angle.